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Topic Group 9: "Paternalistic manipulation of information in justified when giving bad news" Definitions Autonomy: is the capacity of self-determination; it is a person’s ability to make choices about their own life based on their own beliefs and values. In the context of medicine, the principle of autonomy requires healthcare professionals to recognise and support the preferences of patients, provided that they are emotionally and cognitively competentHancock, K., Clayton, J. M., Parker, S. M., Wal der, S., Butow, P. N., Carrick, S., Currow, D., Ghersi, D., Glare, P., Hagerty, R. and Tattersall, M. (2007). Truth-telling in discussing prognosis in advanced life-limiting illnesses: a systematic review. Palliative Medicine, 21(6), 507-517. Paternalism: involves an action that overrides a person’s decision or controls their actions in the interests of what is considered to be their own good. It is described as hard paternalism when the person whose decisions and actions are being controlled is autonomous (competent or capable of making their own decisions). Conversely, soft paternalism is relevant to non-competent individuals who are inherently incapable of making autonomous decisionsMcCarthy J, Donnelly M, Dooley D, Campbell L, Smith D (2011), End-of-Life Care: Ethics and Law, Irish Hospice Foundation. BackgroundCategory:BrowseCategory:Test It is universally accepted that doctors have a responsibility to act obtain informed consent when making healthcare decisions. While patients have the right to non-interference when making decisions about themselves, there is the element of paternalism that exists when doctors are delivering bad news. The case for paternalistic manipulation and conversely, truth-telling in all circumstances will be explored in this article. The case for paternalistic manipulation Paternalistic manipulation of information is often justified when giving bad news because it allows the physician to display compassion to a patient who is involved in a distressing experience. Therapeutic privilege Therapeutic privilege or benevolent deception is a defence that excuses a medical practitioner or other health professional from complying with the requirements of full disclosure to a patient in circumstances where it is reasonably considered that such disclosure would be harmful to that patient's health or welfare. Although the concept originated in the United States, the defence has been applied in Australia, and was specifically endorsed as part of Australian law by the high court in Rogers v WhitakerRogers v Whitaker (1992) 175 CLR 479. However there has been negligible application of the defence since that endorsement despite being widely employed in principalKerridge IH, Lowe M, Stewart C. Ethics and law for the health professions. 4th ed. Annandale, N.S.W.: Federation Press; 2013.. In the case of Battersby v TottmanBattersby v Tottman 1985 37 SASR 524, Mrs Battersby was suffering from a deep-seeded psychosis with symptoms of depression and hallucinations and feelings tending toward homicide and suicide. The only suitable means of controlling her depression and preventing her from attempting suicide was to prescribe large doses of the drug Mellaril, a side-effect of which was severe damage to eyesight. Mrs Battersby, not being informed of this side-effect, used Mellaril for a prolonged period and became blind. She sued the doctor and hospital for negligence claiming she was not properly informed about the risks associated with the treatment. The court found that the doctor had not been in breach of the standard of care that he owed to Mrs Battersby. It was deemed that if he had explained the side-effects, Mrs Battersby was likely to have ceased her medication and have been at substantial risk of committing suicide. The use of therapeutic privilege in this circumstance was justified in that the risk to Mrs Battersby’s health was greater had she been fully informed. To tell her of the side-effects - damage to her eyesight - may have caused her harm and thus excused what may have otherwise been a breach of the standard of care. Thus, when significant harms are introduced by fully informing the patient, manipulation or omission of information can be justified when giving bad news and can be explained and justified further via care ethics and virtue ethics. Care and virtue based ethics Both sides of an ethical issue must be considered on a case-by-case basis. This is the key message of care based ethics and is a strong argument for the justification of paternalism when delivering bad news. Publications such as Girgis and Sanson-Fishers’ Consensus Guidelines for breaking bad newsGirgis A, Sanson-Fisher R. Breaking bad news: consensus guidelines for medical practitioners. Journal Of Clinical Oncology: Official Journal Of The American Society Of Clinical Oncology on the Internet. (1995, Sep), June 12, 2014; 13(9): 2449-2456. and the National Breast and Ovarian Cancer Centre recommendations from 2007 National Breast and Ovarian Cancer Centre. Breaking Bad News: Evidence from the Literature and recommended steps. National Breast and Ovarian Cancer Centre; 2007: Surry Hills NSW.share the common theme of following patient cues when providing information. Methods recommended include: “Discover how much the patient is likely to be able to take in” “Chunking and Checking approach” (breaking information up into small chunks and checking at intervals if the information is being understood and/or if the patient is ready for that information" “Stop the interview if necessary and arrange to resume later” “Patient must be provided with some positive information and hope tempered with realism” Virtue ethics as outlined by Kerridge, Lowe and Stewart 2013, "contains the notion that the rightness or wrongness of action is derived from the underlying motive of the person making that action... It de-emphasises principles, rules and concrete prescriptions". This suggests that paternalistic manipulation of the truth is justified provided the intended consequence is virtuous. The Declaration of GenevaWorld Medical Association. "WMA declaration of Geneva". WMA. Retrieved 12 June 2014. is an oath upheld by the medical profession and among other things states that "The health of my patient will be my first consideration". It is hard than to argue in the face of this guiding mantra and the principles set out via a care and virtue ethic that paternalism is not justified in the delivery of bad news. The case for autonomy and truth-telling The omission or manipulation of information for compassion or beneficence, while benevolent in their intentions, is inherently flawed because it introduces potential harms through reducing patient autonomy and introduces unnecessary risk to the doctor-patient relationship. Reduction of patient autonomy Autonomy is closely linked with the idea of informed consent. Doctors play a large role in ensuring patients are able to make the best choices for themselves by educating them about the benefits and risks of each intervention. Therefore, it is important that information provided to the patient is portrayed accurately, and disclosed in full without manipulation. As patients can often become distressed upon receiving bad news, doctors may be tempted to manipulate the information given in the name of compassion. However, because bad news is often given as background to a potential medical intervention, the manipulation of information for compassionate purposes may misinform the patient and reduce the chances of obtaining ‘true consent’ and hence reduce autonomy. It might be argued that swaying a patient towards the option which is more medically sound has an element of beneficence, and thus manipulation is justified. Moreover, the perceived harm associated with full-disclosure cannot be truly gauged by doctors and is not great enough to justify manipulation. Therefore, in cases where there is a clash between beneficence and autonomy, autonomy usually wins. It is recognised that patients have the right to choose above all else, even if the choices might be viewed by the doctor as bad or self-destructive. Risk to the doctor-patient relationship The doctor-patient relationship is sacrosanct in ensuring good medical practice. Patients put a lot of trust in doctors to manage their health and to act in their best interests. It is this trust that enables patients to discuss their medical problems without fear of embarrassment or judgement and disclose the information required for the doctor to ultimately treat the patient. Upon this foundation of trust, there is a social contract between the two parties that they will be truthful in their dealings with each other. Not only does that require the patient to disclose information required for treatment, but there is an expectation that the doctor must also present information in an accurate manner. If information is manipulated or perceived to be dishonestly presented even in the smallest way, the patient is unlikely to be able to continue with the relationship as there is a perception of betrayed trust. In a world where there is so much information freely available online, the potential for a patient to access medical advice is unprecedented. Thus, the chances of discovering a mismatch or omission on the doctors part has never been greater. In the event that information is omitted, manipulated, or autonomy subverted, there are risks to the doctors integrity and reputation. Moreover, breaches of the Code of Conduct (Good Medical Practice) Australian Medical Council (2009). Good Medical Practice: A Code of Conduct for Doctors in Australia.guidelines can potentially lead to sanctions by the medical board or potential litigation. Therefore, the harms that paternalistic manipulation introduces far outweighs the benefit of compassion. Minimising harms and maximising benefits on a case-by-case basis Doctors deal with situations on a daily basis that require them to justify their views on disclosing sensitive information, and explore the limitations of patient autonomy. More often than not, the arguments for and against paternalistic manipulation tend to rely on absolute principles. For instance, an argument against paternalism could be that manipulating information breaches patient autonomy, and is therefore a clear violation of human rights. Conversely, an argument justifying paternalism would be withholding information that would otherwise cause serious harm or distress to a patient without providing any clinical benefit. While both arguments are ethically justified, they cannot be applied as a blanket rule in all settings. Consider the following hypothetical scenario. A young boy is hospitalised following a motor vehicle accident that killed both his parents. He is in critical condition, and the emotional turmoil of telling him the truth about his parents could likely result in his death. The doctors decide to put off telling him about his parents until he is on his way to recovery. This is a case of beneficence taking precedence over patient autonomy, justified in that the alternative would result in a bad outcome. There are situations which justify the use of paternalistic manipulation which don’t come down to the comparison of autonomy and beneficence. One situation is where patients are competent, pathologies in reasoning exist in the patient. A recent article in the Journal of Medical EthicsLevy (2014). Forced to be free? Increasing patient autonomy by constraining it. Journal of Medical Ethics, 40 (5), pp. 293-300. argues that while autonomy is usually of higher importance when comparing ethical principles, patients often possess cognitive biases and pathologies in reasoning, and make choices which don’t reflect their values. This is exacerbated by emotion or fear. Some of these cognitive biases include: *Hyperbolic discounting: where patients don’t consider the future with enough weight. * Motivated reasoning: where biases can lead to the dismissal of evidence important to the decision. *Affective forecasting: where patients overestimate the effects of events and change of circumstances on their level of wellbeing. *Affective recall: where patients are unreliable in predicting how future events will make them feel, and how past events made us feel. In cases where treatment is paramount for survival, cognitive biases lead to bad decisions, regret, and potentially severe medical harms. Therefore, to reduce these harms, constraints must be applied to informed consent. Using informed consent specialists which can correct cognitive illusions and ensure that decisions are driven by the states of the patient in which they properly identify can help. Measures can be introduced to dissuade patients from changing their minds as a result of hyperbolic discounting, such as requiring a long series of steps to withdraw their consent, such as counselling. However, the final decision must never be taken out of the patients hands. Thus, patients should be helped to make good decisions, even if some of this help comes in the form of confrontation. Patients should be informed when the doctor thinks that they are misapplying their values. This form of mild coercion as a form of paternalistic manipulation can lead to better informed consent, and therefore more autonomy. However, it is hard to know if a patient's choices is due to a failure to reason properly, or a reflection of the wide range of values that patients may possess. Current literatureMcCarthy J, Donnelly M, Dooley D, Campbell L, Smith D (2011), End-of-Life Care: Ethics and Law, Irish Hospice Foundation purports the principle of truth-telling as the most reasonable way of addressing ethical dilemmas where the case for paternalism is contentious. The principle is founded on respect for patient autonomy, but is not absolute. It allows for exceptions in certain specific situations, and requires any and all exceptions to be justified by evidence from the concrete realities of a case. Withholding information, partial deception or total deception is only justified if the full range of human, patient, personal and health realities have been taken into account. Therapeutic privilege is considered as one such exception, but requires caution in its use. As such, the principle of truth-telling can be defined as utilitarian in nature. It stresses that the rightness or wrongness of an action is determined by what follows from the choices of individuals. Hence, an action is considered to be moral if it results in clinical beneficence. This morality does not hold true if the same action leads to suffering and degradation. The challenges of utilitarianism in the principle of truth-telling is clear: doctors must take responsibility for anticipating the outcomes of any form of manipulation. References __FORCETOC__